NPLATE (romiplostim)

NPLATE (romiplostim) 

OFFICE ADMINISTRATION – SC INJECTION

Indications for Prior Authorization

• Chronic immune (idiopathic) thrombocytopenic purpura (ITP)

Patients must meet the following criteria for the indication(s) above:

• Failure/adverse effects from corticosteroids, immunoglobulins, or splenectomy AND
• Baseline platelet count of less than 30,000/ml

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P&T Committee:

• All non-FDA approved uses not listed in the approved indications

Dosing:

• Initial dose 1 mcg/kg once weekly SC
• Do Not Exceed: 10 mcg/kg weekly SC

Approval:

• One month initial
• 6 months provided patient maintains platelet count between 50 and 200 x 10⁹/L